Small Business
EMPLOYEE ENROLLMENT
INSTRUCTIONS Please print neatly. Be sure to fill in the enrollment form completely. Missing or inaccurate information will delay enrollment processing.
Employer 1. Complete section 1 on the enrollment forms. 1A. If enrollment reason is loss of coverage or other, the event must be one of the special enrollment triggering events listed below: • Increase • Return
in an employee’s hours so that he or she meets your requirement for medical plan eligibility
from a leave of absence
• Involuntary • A
termination or loss of other group coverage
dependent loses coverage elsewhere
• Marriage
or addition of a domestic partner
• Birth • Adoption
of a child or placement for adoption
• Court
order
• Death
of a spouse, domestic partner, or dependent
2. Give each enrolling employee an enrollment form to complete. 3. Confirm that the information provided by employees on their enrollment forms is complete and accurate. 4. Return the completed enrollment forms to your broker or Kaiser Permanente.
Employee 1. Complete sections 2 through 4. 2. Sign and date the form. 3. Make a copy of the form for your records.
This form serves as your temporary Kaiser Permanente member ID. Please make a copy and keep it until you receive your official member ID.
Small Business 60466408 July 2016
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Small Business
EMPLOYEE ENROLLMENT See instructions on page 1 before completing this form. Make a copy for your records.
1 TO BE COMPLETED BY EMPLOYER
New group account
Company name
Existing account
Customer ID (if assigned)
Date of coverage to be effective / / Employee classification (if applicable)
Plan selection Employee last name
Employee first name
Enrollment reason (Please check 1)
New group account
New hire
Loss of coverage
Other:
MI
Open enrollment
Part-time to full-time
If you have an existing account, please fax this form to 858-614-3345 (SCAL), 858-614-3344 (NCAL), or email
[email protected].
2 TO BE COMPLETED BY EMPLOYEE Have you ever been a member of, or received care from, Kaiser Permanente in California? If so, under what medical record number (if known)
Yes
Social Security number
Last name
No Former/Maiden name
First name
MI
Preferred language (optional)
Home address (no P.O. boxes) City
State
Date of birth /
Gender /
M
F
ZIP Home phone ( )
–
County Office phone ( )
–
If you decline coverage for yourself or an eligible dependent, you can only enroll or change your coverage during an annual open enrollment period established by your employer, or during a special enrollment period if you have experienced a triggering event. You must request coverage within 60 days of a triggering event. Special enrollment triggering events include: • Loss of health care (minimal essential) coverage, resulting from any of the following: loss of employer-sponsored coverage because you and/or your dependent no longer meet the eligibility requirements, or your employer no longer offers coverage or stops contributing premium payments; loss of eligibility for COBRA coverage (for a reason other than termination for cause or nonpayment of premium); your and/or your dependent’s individual, Medi-Cal, Medicare, or other governmental coverage ends; or for any reason other than failure to pay premiums on a timely basis or situations allowing for a rescission (fraud or intentional misrepresentation of material fact); or loss of health care coverage including, but not limited to, loss of that coverage due to the circumstances described in Section 54.9801-6(a)(3)(i) to (iii), inclusive, of Title 26 of the Code of Federal Regulations and the circumstances described in Section 1163 of Title 29 of the United States Code; • Gaining or becoming a dependent due to marriage, domestic partnership, birth, adoption, placement for adoption, or assumption of a parent-child relationship; • A valid state or federal court orders that you or your dependent be covered; • Permanent relocation, such as moving to a new location and having a different choice of health plans, or being released from incarceration; • The prior health coverage issuer substantially violated a material provision of the health coverage contract; • A network provider’s participation in your and/or your dependent’s health plan ended when you and/or your dependent(s) were under active care for one of the following conditions: an acute condition (an acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration); a serious chronic condition (a serious chronic condition is a medical condition due to a disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration); pregnancy; terminal illness (a terminal illness is an incurable or irreversible condition that has a high probability of causing death within one year or less); care of a newborn child between birth and age 36 months; or performance of a surgery or other procedure that has been recommended and documented by the provider to occur within 180 days of the contract’s termination date or within 180 days of the effective date of coverage for a newly covered insured; • A member of the reserve forces of the United States military returning from active duty or a member of the California National Guard returning from active duty service under Title 32 of the United States Code; • An individual demonstrates to the Department of Managed Health Care or Department of Insurance, as applicable, with respect to health benefit plans offered outside the Exchange that the individual did not enroll in a health benefit plan during the immediately preceding enrollment period available because the individual was misinformed that he or she was covered under minimum essential coverage. Small Business 60466408 July 2016
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Small Business
EMPLOYEE ENROLLMENT 3 FAMILY INFORMATION (Please list only those family members to be enrolled.) Spouse
Domestic partner
Date of birth (mm/dd/yyyy)
/
Gender
/
Name (Last, First, MI)
Dependent
Date of birth (mm/dd/yyyy)
/
Gender
/
Date of birth (mm/dd/yyyy)
/
Gender
/
Date of birth (mm/dd/yyyy)
/
Gender
/
Date of birth (mm/dd/yyyy)
/
Gender
/
Social Security number
M
F
Social Security number
M
F
Social Security number
M
F
Social Security number
Medical record number (if known) Date of birth (mm/dd/yyyy)
/
Gender
/
Name (Last, First, MI)
M
F
Social Security number
Medical record number (if known)
Do any of your dependents listed above live at another address? Name (Last, First, MI)
F
Medical record number (if known)
Name (Last, First, MI)
Dependent
M
Medical record number (if known)
Name (Last, First, MI)
Dependent
Social Security number
Medical record number (if known)
Name (Last, First, MI)
Dependent
F
Medical record number (if known)
Name (Last, First, MI)
Dependent
M
Yes
No
If Yes, complete the following:
Address
4 SIGNATURE KAISER FOUNDATION HEALTH PLAN, INC., ARBITRATION AGREEMENT* I understand that (except for Small Claims Court cases, claims subject to a Medicare appeals procedure or the ERISA claims procedure regulation, and any other claims that cannot be subject to binding arbitration under governing law) any dispute between myself, my heirs, relatives, or other associated parties on the one hand and Kaiser Foundation Health Plan, Inc. (KFHP), any contracted health care providers, administrators, or other associated parties on the other hand, for alleged violation of any duty arising out of or related to membership in KFHP, including any claim for medical or hospital malpractice (a claim that medical services were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered), for premises liability, or relating to the coverage for, or delivery of, services or items, irrespective of legal theory, must be decided by binding arbitration under California law and not by lawsuit or resort to court process, except as applicable law provides for judicial review of arbitration proceedings. I agree to give up our right to a jury trial and accept the use of binding arbitration. I understand that the full arbitration provision is contained in the Evidence of Coverage. Employee signature
Date
X Employee name (please print)
Title (please print)
* Disputes arising from fully insured Kaiser Permanente Insurance Company (KPIC) coverage are not subject to binding arbitration: 1) the Preferred Provider Organization (PPO) and the out-of-network portion of the Point-of-Service (POS) plans; 2) Preferred Provider Organization (PPO) plans; 3) Out-of-Area Indemnity (OOA) plans; and 4) KPIC Dental plans. Small Business 60466408 July 2016
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